Fate of the exposed saphenous vein graft

Patients with functioning vein grafts may present with wound problems resulting in exposure of the graft. We reviewed the courses of 16 patients presenting with this problem to determine the causative factors and the most appropriate management of this therapeutic dilemma. Diabetes mellitus (11 of 16, 68.7%) and wound infection (12 of 16, 75%) were frequent pre-existing conditions associated with exposed venous grafts. All patients with exposed vein grafts were initially treated conservatively with regular application of moist sterile dressings, followed by split-thickness skin graft coverage of the wounds when clean. The wounds healed in 7 patients, whereas 9 patients developed complications of hemorrhage (7 patients) and graft thrombosis (2 patients). The outcome of therapy was highly dependent on the type of organism originally cultured from the wounds. The incidence of vein graft disruption was lowest when the wounds were sterile (25%) or when gram-positive bacteria grew (25%). Gram-negative infection uniformly resulted in disruption of the exposed venous graft. When a new graft was placed, the secondary graft became reinfected in all patients with gram-negative primary graft infection. There were no instances of secondary graft reinfection when gram-negative bacteria were not present. These data suggest that the outcome of patients presenting with exposed vein grafts is highly dependent on the bacterial flora of the process. Vein graft disruption is frequent in patients with gram-negative infection, suggesting that these patients should be treated with distant graft ligation and extra-anatomic bypass. By contrast, patients without gram-negative infection may be successfully managed with local wound care.